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Maxillofacial trauma with head injuries at a

tertiary care hospital in Chitwan, Nepal:
Clinical, medico-legal, and critical care...

Article in Turkish Journal of Medical Sciences · December 2012

DOI: 10.3906/sag-1202-63

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 Turk J Med Sci
2012; 42 (1):
© TÜBİTAK
E-mail: medsci@tubitak.gov.tr
Original Article doi:10.3906/sag-1202-63

Maxillofacial trauma with head injuries at a tertiary care

hospital in Chitwan, Nepal: clinical, medico-legal,
and critical care concerns of
ro
p
Santosh Kumar YADAV1, Birendra Kumar MANDAL2, Abhishek KARN2, Ajit Kumar SAH3

e y
ll
ga
Aim: Maxillofacial trauma is commonly associated with other injuries, predominantly head injuries. The present
study aimed to evaluate types of injury, management, and outcome of patients sustaining maxillofacial trauma and
concomitant cranial injuries.
Materials and methods: A retrospective study was carried out in the department of oral and maxillofacial surgery. A
case series of 63 patients who were admitted to the intensive care unit with maxillofacial trauma and head injuries was
evaluated. The data were then compiled systematically and analyzed using SPSS for Windows and values of P < 0.05 were
considered significant and P < 0.0001 as highly significant.
Results: Among the 63 patients, the majority of them had had roadside accidents (90%) and there was a predominant sex
bias with a male to female ratio of 7:1. Fractured maxilla and nasal bones were the most commonly encountered injuries
(49.21%), followed by mandibular fractures (38.09%). Forty-two patients (66.67%) required mechanical ventilation,
tracheostomy was needed in 19 (30.16%) patients, and 42 (66.67%) patients were operated on for head injuries. The
majority of the victims were aged between 15 and 40 years.
Conclusion: Maxillofacial trauma with head injuries demands special attention as airway compromise is invariably
present. Equally critical is the surgical intervention as simultaneously cranial and maxillofacial surgeries were performed.
Preventive measures and legislation regarding traffic rules require a review also as the higher incidence of accidents
among young adults has acquired epidemic status.

Key words: Maxillofacial injury, craniofacial trauma, road traffic accidents, head injuries, mechanical ventilation,
tracheostomy, tracheal intubation

Introduction use of mobile phones while driving is acquiring an

The increasing number of road traffic accidents epidemic proportion and the number of accidents
(RTAs) in Nepal has made it extremely difficult to during such negligent driving has not been reported
analyze the exact reported incidence of mortality and accurately. The incidence of maxillofacial trauma and
morbidity due to airway and facial trauma. The day airway involvement as a result of roadside accidents
by day increasing competition in all fields has reduced is quite varied and an approximate incidence of
the chances of employment. As a result, the younger 22% is reported from developed countries (1–3). In
generation has to move from place to place in search Nepal alone, accidents account for the highest fatality
of a suitable job and sometimes the job demands rate, reaching a peak of almost 15–20 times that of
too much travelling on their part. The increasing developed nations. RTAs have acquired an epidemic
Received: 16.02.2012 – Accepted: 01.06.2012
1
Department of Oral and Maxillofacial Surgery, Chitwan School of Medical Sciences, Bharatpur-10, Chitwan – NEPAL
2
Department of Forensic Medicine and Toxicology, Chitwan School of Medical Sciences, Bharatpur-10, Chitwan – NEPAL
3
Department of Pharmacology, Chitwan School of Medical Sciences, Bharatpur-10, Chitwan – NEPAL
Correspondence: Santosh Kumar YADAV, Department of Oral and Maxillofacial Surgery, Chitwan School of Medical Sciences, Bharatpur-10, Chitwan - NEPAL
E-mail: santoshsoni_2000@yahoo.com

1
Maxillofacial trauma with head injuries
proportion and are putting an extra burden on our
health resources (4–6).
The primary management of the injuries,
specifically to the airway and facial structures, is of
prime importance to the attending anesthesiologist
and the intensivist. Maxillofacial trauma is invariably
associated with head injuries and injuries to the other
vital organs can further increase the mortality and
morbidity statistics. Although there is heterogeneity
in the actual reported incidences of such trauma,
the common denominator in the majority of these
accidents is the involvement of young males (7,8),
and orbito-zygomatic complex fractures account for
a significant component of facial trauma affecting
young people (9). Many times the role of alcohol and
drug addiction cannot be overlooked.
A thorough knowledge of the anatomy of the
face and airway is essential and helps in saving many
lives. Equally important is the availability of back-up
services like an intensive care unit (ICU) and trauma
team so that the necessary interventions are carried
out at the earliest possible time.
The present review was carried out to analyze
retrospectively the demographic profile of the
patients, nature of injuries, types of interventions
needed, factors responsible for such trauma,
management of these injuries and the outcome in
these patients, medico-legal and ethical aspects, and
a genuine attempt to identify preventable factors in
such injuries.
Materials and methods
After obtaining permission from the concerned
hospital authorities, we reviewed retrospectively
the records of 63 patients who had sustained
maxillofacial trauma and concomitant head injury
over the previous 2 years. The institute is located on
a highway, catering to a 2.5–3 hundred thousand
rural population. The study specifically stresses
upon the facts related to the demographic profile
of the patients, nature and type of injuries, factors
responsible for infliction of such injuries, need
for airway management/intubation and possible
mechanical ventilation, need for tracheostomy, and
the outcome in such patients due to the availability of
multiple support facilities.
2
Little time was lost in bringing these patients to
the emergency department (ED) as our institute is
located on the national highway with an easy approach
and access. The services of the well-equipped hospital
ambulances were sought in many cases with the wide
publicity through emergency helpline numbers.
In the ED a rapid assessment of the general
condition of the patients was carried out by the
trauma team. A rapid clinical examination and
airway assessment were made by the attending
anesthesiologist using the Glasgow Coma Scale
(GCS) score, MP grading, thyro-mental distance,
and cervical spine assessment for the possible need
to secure the airway. The airway management either
in the ED or ICU did not pose much difficulty as a
fiber optic bronchoscope was available.
After establishing and securing the airway
and carrying out the primary resuscitation, blood
samples were sent for the required investigations
including the necessary radiological investigations
like computed tomography scan, ultrasound, and
X-rays. Patients who required immediate operative
intervention were shifted to the emergency operation
theater after stabilizing their clinical condition
and optimization of hemodynamic status. The
rest of the patients were shifted to the ICU for
further observation and management and after the
necessary surgical procedure operated patients were
also shifted to the ICU. Mechanical ventilation was
carried out as and when required while tracheostomy
was also performed in a few patients for various
indications. Delayed surgical interventions were also
carried out after initial conservative management
especially for maxillofacial trauma. During their
stay in the ICU routine monitoring was carried out,
which included heart rate, blood pressure, pulse
oximetry, ECG, end tidal carbon dioxide etc. Day
to day investigations was carried out to monitor and
individualize the treatment. Only those patients that
regained consciousness and had a good recovery
were discharged. At the end of study all the data
were arranged and compiled systematically and
were subjected to statistical analysis using Mann–
Whitney and chi-square tests using SPSS version
10.0 for Windows. Values of P < 0.05 were considered
significant and P < 0.0001 as highly significant.

Results
A total of 378 patients were admitted to the ED of
our institute in the past 2 years with polytrauma and
multiple injuries. Out of these, 63 patients sustained
injuries to facial structures and the cranium alone
with associated minor injuries to other organs. The
majority of these patients were victims of RTAs that
were brought in either by relatives and friends or
by passersby and police officers. In majority of the
cases, the trauma ambulance of our institution was
also pressed into service. The demographic profile of
these patients is shown in Table 1.
The demographic profile of our patients throws
light on some significant facts. The number of
patients who suffered RTAs was significantly higher
in the age group of 15–40 years (P < 0.0001). The male
sex predominance (87.30%) among these victims was
statistically significant (P < 0.0001) as was the alcohol
consumption (36.50%). Another finding of statistical
significance (P<0.0001) was that majority of these
victims (73.02%) had a rural background. The mean
time for initiation of resuscitative efforts from the
time of injury was calculated to be about 30.32 min
with a standard deviation of 7.42 (Table 1).
The numbers of motorbike victims were
significantly higher (55.56%) than the cyclists,
Table 1. The demographic profile of craniofacial trauma victims.
Demographic characteristics
(total no. of patients n = 63)
Age
Sex
Location
Alcohol/drug intake
Time to trauma and initial resuscitation in
minutes (mean ± standard deviation)
**P < 0.0001
S. K. YADAV, B. K. MANDAL, A. KARN, A. K. SAH
pedestrians, and persons in four wheelers like cars,
jeeps, etc. who sustained injuries during RTAs (Table
2). There were a few patients (7.93%) who were
admitted with maxillofacial trauma and head injury
after a fall from a height and assault during personal
altercations. All these patients were reported to the
police after admission by the emergency medical
officer from the medico-legal perspectives. The mean
GCS score in these patients was estimated to be 11.2.
The nature of injuries among these patients
showed a variety of patterns (Table 3). Thirty-
one patients suffered fractures of the maxilla and
nasal bones while 24 patients suffered mandibular
fractures. Among the head injuries with maxillofacial
trauma extradural hematoma (EDH) (22.22%) was
the most common finding, followed by subdural
hematoma (SDH) (17.46%) and subarachnoid
hemorrhage (SAH) (14.28%). The injuries to the
skull included fractures of the frontal bone (20.63%),
sphenoid bone (11.11%), and orbital roof (14.28%),
and fracture of the cribriform and ethmoid bone
complex (15.87%) with associated cerebrospinal fluid
(CSF) rhinorrhea. There were associated injuries to
other organ systems as well (34.92%) that were not
life threatening and included undisplaced fractures
of minor bones including the ribs, abrasions, bruises,
and lacerations to various soft tissue structures.
Number of patients
Percentage
>60 years: 3 4.76
40–60 years: 6 9.52
15–40 years: 48** 76.19
5–15 years: 4 6.34
Preschoolers: 2 3.17
Male: 55** 87.30
Female: 8 12.70
Rural: 46** 73.02
Urban: 17 26.98
23 36.50
30.32 ± 7.42
3
Maxillofacial trauma with head injuries
Table 2. The modes of transportation used by the victims.
Cause of injury
Motorbike
Four wheelers
Pedestrians/cyclists
Fall from the height/assault
Mean GCS score on admission
*P < 0.0001
The presenting clinical picture of these patients
exhibited a huge diversity (Table 4). Ear, nose, and
throat (ENT) bleeding was present in a significant
percentage of the patient population (76.19%). Loss
of consciousness (36.51%), restlessness and agitation
(28.57%), dyspnea and chest pain (17.46%), and
vomiting (11.11%) on admission were the other
presenting symptoms and signs. The majority of
these patients (93.65%) presented with associated
superficial bruises, abrasions, lacerations, and
external soft tissue injuries.
In 36 (57.14%) patients, immediate airway
protection and intubation were mandatory on
account of their airway trauma, respiratory distress,
deteriorating clinical condition, intra-oral bleeding,
and progressively decreasing GCS score (Table
5). Among 63 admissions immediate emergency
operative intervention was required in 29 (46.03%)
patients who had sustained head injuries, while
Table 3. The nature of injuries sustained by the patients.
Nature of injury
Fracture of maxilla and nasal bones
Fracture of mandible
EDH
SDH
SAH
Frontal bone fracture
Cribriform/ethmoid complex injury
Sphenoid bone fracture
Orbital roof fracture
Associated injuries to other organs
4
Number of patients/percentage
35** (55.56)
13 (20.63)
10 (15.87)
5 (7.93)
11.2
delayed surgery was carried out for head injuries
as well as the repair of facial bones in 34 (53.97%)
of the patients. Mechanical ventilation was carried
out in 66.67% of the patients as and when required
during different stages of their stay in the ICU. Blood
transfusion was required due to a presenting picture of
severe hemorrhage or due to ongoing losses in ED in
28.57% of the victims, while 20.63% of these patients
required ionotropic support as well for maintaining
hemodynamic stability. Chest tube insertion was
necessary in 6.34% of the patients due to the
presenting pneumo-hemothorax. Tracheostomy was
performed in 30.16% of the patients and surprisingly
this was performed as an elective procedure for
various indications and the availability of a fiber optic
bronchoscope negated the need for surgical airway
intervention in the ED. We observed a mortality of
12.70% in these patients and that mainly involved the
patients with GCS scores of less than 5 (Table 5).
Number of patients (n = 63) Percentage
31 49.21
24 38.09
14 22.22
11 17.46
9 14.28
13 20.63
10 15.87
7 11.11
9 14.28
22 34.92
 S. K. YADAV, B. K. MANDAL, A. KARN, A. K. SAH

Table 4. The clinical presentation of signs and symptoms on admission.

Presenting clinical picture Number of patients Percentage

ENT trauma/bleeding 48* 76.19

Loss of consciousness 23 36.51
Restlessness/agitation 18 28.57
Dyspnea/chest pain 11 17.46
Circulatory shock 12 19.05
Vomiting 7 11.11
Associated lacerations, bruises, abrasions,
59 93.65
and external soft tissue injuries

Discussion where young male predominance is a common

The inclusion of combined maxillofacial trauma and
head injury patients only in the present study was
deliberate as the basic concept revolved around the
airway and intensive care management and not the
surgical aspect alone. The study intended to analyze
vital statistics due to craniofacial trauma alone and it
was independent of the impact of other concomitant
injuries that could have raised the statistical figures of
mortality and morbidity. The emphasis was upon the
factors responsible for injuries, types of interventions
needed specifically for airway management, the
outcome of timely management, and the impact of
availability of ICU services and a trauma team in the
prognosis of these serious fatal injuries.
The demographic characteristics of craniofacial
trauma are no different from those due to polytrauma
characteristic and in the majority of cases alleged
alcohol consumption is invariably present (2,9–13).
The higher consumption of alcohol and substance
abuse in this country has further enhanced the
statistical record of RTAs. Alcohol consumption
was a common denominator in 36.50% of our
patients. Another major reason is that males in our
Nepali society, whether young or old, tend to take
responsibility upon themselves to carry out all the
away from home chores (2,3,10–12).
The biggest drawback during initial care includes
a lack of proper pre-hospital care and the timely
transportation of these accident victims to the health
centers (14,15). From time to time various guidelines
have been published dealing with craniofacial
trauma but to date there is no universally accepted

Table 5. The initial diagnosis, clinical procedures, resuscitation, and the other later therapeutic interventions carried out in these trauma
victims.

Initial admission, diagnosis, management, and

Number of patients Percentage
resuscitation statistics
Airway management and intubation 36 57.14
Emergency operative intervention within first 6 h 29 46.03
Delayed surgery 34 53.97
Mechanical ventilation 42 66.67
Immediate blood transfusion requirement. 18 28.57
Ionotropic requirement 13 20.63
Chest tube insertion 4 6.34
Tracheostomy 19 30.16
Survival/mortality statistics 55/8 87.30/12.70

5
Maxillofacial trauma with head injuries
protocol for managing and preventing this menace
in developing nations like Nepal (16). The popularity
of pre-hospital trauma life support guidelines has
increased manifold in the west but progress has been
slow in this country due to a multitude of problems.
Trauma patients have been considered to require
expedient transport because they are thought to
require a short amount of time between injury and
surgical intervention. Patients have the best chance
of survival if they reach a trauma center within 1 h of
injury; the duration is considered the golden hour in
the emergency management of RTAs (17).
The most common clinical presentation of these
patients to the ED includes loss of consciousness,
agitation and restlessness, oro-nasal bleeding,
facial swelling, respiratory distress, and vomiting,
and a similar scenario was observed in our study
as well (14,18). The most common indication for
immediate surgical intervention included depressed
skull fracture, EDH, SDH, brain contusion with
intracranial bleeding, CSF rhinorrhea, and fractured
maxillofacial bones interfering with the airway.
Airway management is of prime importance in these
patients as facial fractures, oro-nasal bleeding, and
disrupted facial anatomy present huge challenges to
the attending intensivist when securing the airway.
Equally critical becomes the support of circulation as
the trauma in these patients is invariably associated
with circulatory shock (14,18).
Craniofacial trauma causes numerous challenges
when patients are first attended to in the hospital.
If the identity of the victim is in doubt, it opens
the doors to numerous medico-legal concerns
about the initiation of advanced treatment after
the completion of initial resuscitative efforts.
Many times, a decision has to be made urgently as
head injuries and other associated life-threatening
injuries require urgent operative intervention (19).
Emergency surgery in craniofacial trauma is further
warranted by CSF leak, which occurs in 11%–12%
of patients with basal skull fractures (20) and the
incidence in our study extended to 15%. The main
goals of neurosurgical intervention at the earliest
stage are to prevent irreversible pressure changes in
the brain and external deformity of the skull, to seal
the CSF leak, and to avoid meningitis and sinusitis.
6
Sometimes, after the initial resuscitation, surgery is
delayed as a result of optimization of hemodynamic
status and regression of soft tissue swelling. Long-
term complications of such injuries include muco- or
pyocele, meningitis, subdural empyema, and brain
abscess. The controversy is never ending with regards
to indication for surgery, timing of surgery, the best
operative approach, the choice of material to close
dural leaks and bone defects, etc. (20).
The priority for surgery in craniofacial trauma
should be based on a collaborative interdisciplinary
approach. This warrants close coordination between
the neurosurgeon, anesthesiologist, intensivist,
maxillofacial surgeon, plastic surgeon, and ENT
specialist during the process of precise diagnosis,
decision about the time of surgery and surgical
approach, and availability of intensive care facilities
(21). Our task became much simpler as we have a
well-equipped trauma unit and a trauma team that is
always available in the hospital for dealing with any
type of emergency or mass disaster.
The traditional surgical management of complex
craniofacial trauma is usually performed in 3
stages where immediate craniotomy is followed
by orbitofacial repair in 7–10 days and last of all
cranioplasty is carried out after 6–12 months (22).
However, early single stage repair of craniofacial
trauma was carried out in 12 of the craniofacial
trauma victims due to massive disruption of facial
bones and CSF rhinorrhea. Previous studies have
also concluded that such intervention can be
undertaken with an acceptable rate of morbidity and
mortality, a decreased need for re-operation, and
improved cosmetic and functional outcome. Further
considerations in our cases include decreased ICU
stay, cost-effectiveness, and less anesthetic exposure.
The big question, however, in these circumstances
pertains to obtaining valid consent for such an
emergency operative intervention. This problem was
faced by us in 12.70% of patients with craniofacial
trauma who had a severe degree of intracranial
bleeding and disruption of facial bones that
necessitated an emergency operative intervention.
Consent for surgery was obtained from the appropriate
hospital authorities to proceed with surgery as that
was the only possible life-saving measure. Otherwise

a delay in implementing the appropriate therapy
could have put their lives at severe risk. There is huge
debate about such interventions and on the basis of
medico-legal aspects the answer to such problems
is simple and that is not to undertake any surgical
intervention in such circumstances. However, if
we keep an ethical approach in mind and abide by
the Hippocratic Oath, such operative interventions
should be undertaken to save precious lives. Certain
protocols and amendments are also required in the
constitution to deal with such delicate matters.
In certain other cases when the patient is identified
but the relatives express their inability to bear the
expenses of surgery and intensive care, a huge
dilemma is created for the attending doctors because
these types of injuries take little time but definitely
these interventions are life saving. Referring them to
another tertiary government institute again seems
to be unethical as not only will it result in time-
consuming transportation and wasting precious
life-saving moments but will also not ensure that
they receive timely and appropriate treatment there.
The novel solution to this problem at least in our
hospital included a clause for free treatment, which
is provided to 25%–30% of such poor patients who
are fighting for their lives in the emergency ward and
ICU.
The provision of such a treatment methodology
is insufficient and the root cause of this menace has
to be treated at both regional and national levels.
Education of the public about all the risk factors
for accidents and their hazards has to be properly
disseminated. At a local level our institute has been
continuously organizing various educational and
awareness camps related to the timely management
of all the medical and surgical emergencies and
cover more than 40 villages with a total population
of more than 4–5 hundred thousand. Continuing
the efforts on similar lines, the institute is providing
training to various volunteers from all these villages
and teaching them how to effectively deal with
such emergencies especially related to pre-hospital
care and transportation. The institute has deployed
ambulances at various critical points along with
helpline numbers to deal with such emergencies.
The incidence of spinal injury is approximately
10% in such trauma cases but surprisingly we
S. K. YADAV, B. K. MANDAL, A. KARN, A. K. SAH
observed cervical spine injury in only 2 patients and
fortunately there were no significant neurological
deficits in these patients (23). The lower incidence
can also be possibly explained on the basis of lower
number of total cases in our study, which may have
influenced the statistics.
As per the American College of Surgeons
Advanced Trauma Life Support [ATLS] Eastern
Association for the Surgery of Trauma guidelines, a
missed or delayed diagnosis of cervical spine injury
may be associated with permanent neurological
damage (24). With the GCS, no consumption of
intoxicants and drugs, no significant distracting
injuries, and no signs or symptoms related to cervical
spine injury are the essential parameters to exclude
the diagnosis, but it was not possible in 36.50% of
patients as they were under the influence of alcohol
and the GCS could not be measured with preciseness.
Craniofacial trauma should be managed
on a priority basis with an emphasis on initial
resuscitation measures including securing the airway,
hemodynamic stabilization, and evaluation and
treatment of injuries to other vital organs (25). The
decision for early and delayed surgical intervention
can be well made by a thorough discussion of the case
between the various specialists of the trauma team.
Conclusions
Maxillofacial trauma with head injuries demands
special attention as airway compromise is invariably
present. Equally critical is the surgical intervention
as simultaneously cranial and maxillofacial surgeries
were performed. The management of craniofacial
trauma requires special efforts from the well-trained
trauma team and the early referral of such injuries
to a well-equipped health center does decrease
the incidence of mortality and morbidity. The role
of pre-hospital care and pre-hospital trauma life
support guidelines is as important as advanced
trauma life support measures. Preventive measures
and legislation regarding traffic rules require a review
also as the higher incidence of accidents among
young adults has acquired epidemic proportions.
Certain amendments to the constitution as well as
strict compliance to road traffic rules are essential to
decrease the incidence of such injuries.
7
Maxillofacial trauma with head injuries

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